Antipsychotic of choice for “Schizo-Obsessive” Disorder?

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There is growing evidence that patients with comorbid obsessive-compulsive disorder (OCD) and schizophrenia may represent a special category of the schizophrenia population (“Schizo-Obsessive”).

Atypical antipsychotics (Dopamine-Serotonin Antagonist) are more likely to exacerbate Obsessive-Compulsive symptoms (OCS), compared to typical antipsychotics.

MECHANISM:

Atypical antipsychotics (Dopamine-Serotonin Antagonist) blocks 5HT2A receptor in presynaptic dopamine neuron –> disinhibit dopaminergic activity –> postulated to increase OCS in pt with schizophrenia.

Q: Which Antipsychotic is least likely to exacerbate OCD symptoms in this population?

Amisulpride:

This is an atypical antipsychotic is selective dopamine blocker, with a low affinity for 5HT2A receptor –> resultant antiobsessional effects.

Second option after Amisulpride is Aripiprazole.

Aripiprazole is a potent 5HT2A antagonist with a partial dopamine agonist –> thus causing relatively weak dopamine D2 blockade –> thus pharmacologically even Aripiprazole can result in exacerbation of OCS symptoms.

However, the following two studies (small open-label prospective study and double-blind trial) showed the efficacy of Aripiprazole in OCS in schizophrenia.

References:

Sayyah M. Depress Anxiety. 2012;29:850-854.,
Kim SW, Clinc Neuropsychopharmacol 2009;32:243-249.
Also read Psychiatric Annals Oct 2013 issue on Comorbidities in Schizophrenia.

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Obsessive Compulsive and Related Disorders

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